Cardiovascular Disease and the
Patient with Diabetes and
Metabolic Syndrome
Nathan D. Wong, PhD, FACC, FAHA
Professor and Director
Heart Disease Prevention Program
Division of Cardiology
University of California, Irvine
President, American Society for
Preventive Cardiology
Presenter Disclosure
• Dr. Wong has received research support
through Bristol-Myers Squibb, Novartis,
and Forest Laboratories through the
University of California, Irvine
Presentation Objectives
• Review the epidemiology implicating
metabolic syndrome and diabetes in
cardiovascular risk
• Discuss the clinical trial evidence for the
role of lifestyle management, glycemic,
lipid, and blood pressure control.
• Address the ABCs of lifestyle and clinical
management of metabolic syndrome and
diabetes aimed to reduce cardiovascular
disease risk.
Diagnosed Diabetes in the US: 2008
CDC BRFSS: Self-Reported Diabetes: 8.2% Nationwide
4 – 6%
6 – 8%
http://apps.nccd.cdc.gov/brfss/list.asp?cat=DB&yr=2008&qkey=1363&state=All
8 – 10%
10 – 12%
14.9
Percent of Population
16
14.2
13.1
14
11.3
12
10
8
6
6.1
5.8
4
2
0
Men
NH Whites
Women
NH Blacks
Mexican Americans
Prevalence of physician-diagnosed diabetes in Adults age 20
and older by race/ethnicity and sex (NHANES: 2005-2006).
Source: NCHS and NHLBI. NH – non-Hispanic.
The Continuum of CV Risk in Type 2
Diabetes
Adapted from American Diabetes Association. Diabetes Care. 2003;26:3160-3167.
Tsao PS, et al. Arterioscler Thromb Vasc Biol. 1998;18:947-953.
Hsueh WA, et al. Am J Med. 1998;105(1A):4S-14S.
American Diabetes Association. Diabetes Care. 1998;21:310-314.
Diagnostic Criteria for Metabolic
Syndrome: Modified NCEP ATP III
≥3 Components Required for Diagnosis
Components
Defining Level
Increased waist circumference
Men
Women
Elevated triglycerides
Reduced HDL-C
Men
Women
Elevated blood pressure
Elevated fasting glucose
AHA/NHLBI Scientific Statement; Circulation 2005; 112:e285-e290.
≥ 40 in
≥ 35 in
≥150 mg/dL
(or Medical Rx)
<40 mg/dL
<50 mg/dL
(or Medical Rx)
≥130 / ≥85 mm Hg
(or Medical Rx)
≥100 mg/dL
(or Medical Rx)
IDF Criteria: Abdominal Obesity and
Waist Circumference Thresholds
Men
Women
Europid
≥ 94 cm (37.0 in)
≥ 80 cm (31.5 in)
South Asian
≥ 90 cm (35.4 in)
≥ 80 cm (31.5 in)
Chinese
≥ 90 cm (35.4 in)
≥ 80 cm (31.5 in)
Japanese
≥ 85 cm (33.5 in)
≥ 90 cm (35.4 in)
• AHA/NHLBI criteria: ≥ 102 cm (40 in) in men, ≥ 88 cm (35 in) in women
• Some US adults of non-Asian origin with marginal increases should benefit
from lifestyle changes. Lower cutpoints (≥ 90 cm in men and ≥ 80 cm in
women) for Asian Americans
Alberti KGMM et al. Lancet 2005;366:1059-1062. | Grundy SM et al. Circulation 2005;112:2735-2752.
Prevalence (%)
Prevalence of the Metabolic Syndrome
Among US Adults NHANES 1988-1994
45
40
35
30
25
20
15
10
5
0
Men
Women
20-29
30-39
Ford E et al. JAMA. 2002(287):356.
40-49
50-59
60-69
> 70
Age (years)
1999-2002 Prevalence by IDF vs. NCEP Definitions (Ford ES,
Diabetes Care 2005; 28: 2745-9) (unadjusted, age 20+)
NCEP : 33.7% in men and 35.4% in women
IDF:
39.9% in men and 38.1% in women
Diabetes and CVD
• Atherosclerotic complications responsible for
– 80% of mortality among patients with diabetes
– 75% of cases due to coronary artery disease
(CAD)
– Results in >75% of all hospitalizations for diabetic
complications
• 50% of patients with type 2 diabetes have
preexisting CAD. (This number may be less now
that more younger people are diagnosed with
diabetes.)
• 1/3 of patients presenting with myocardial
infarction have undiagnosed diabetes mellitus
Lewis GF. Can J Cardiol. 1995;11(suppl C):24C-28C
Norhammar A, et.al. Lancet 2002;359;2140-2144
Risk of Cardiovascular Events in Patients
with Diabetes: Framingham Study
_________________________________________________________________
Cardiovascular Event
Age-adjusted
Biennial Rate
Per 1000
Men Women
Age-adjusted
Risk Ratio
Men Women
Coronary Disease
Stroke
Peripheral Artery Dis.
Cardiac Failure
All CVD Events
39
15
18
23
76
1.5**
2.9***
3.4***
4.4***
2.2***
21
6
18
21
65
2.2***
2.6***
6.4***
7.8***
3.7***
_________________________________________________________________
Subjects 35-64 36-year Follow-up
**P<.001,***P<.0001
7-year incidence rate of MI
Diabetes as a CHD Risk Equivalent:
Type 2 DM and CHD
7-Year Incidence of Fatal/Nonfatal MI
(East West Study)
P<0.001
P<0.001
45.0%
50
40
30
18.8%
20.2%
20
10
3.5%
0
No DM, No MI
No DM, MI
No Diabetes
DM, No MI
DM, MI
Diabetes
CHD=coronary heart disease; MI=myocardial infarction; DM=diabetes mellitus
Haffner SM et al. N Engl J Med. 1998;339:229-234.
Cardiovascular Disease (CVD) and Total
Mortality: U.S. Men and Women Ages 30-74
(Risk-factor adjusted Cox regression) NHANES II Follow-Up (n=6255)
7
***
6
***
Relative Risk
5
***
4
***
***
3
***
***
***
*** ***
2
*
**
None
MetS
Diabetes
CVD
CVD+Diabetes
1
0
CHD Mortality
CVD Mortality
Malik and Wong, et al., Circulation 2004; 110: 1245-1250.
Total Mortality
* p<.05, ** p<.01, **** p<.0001 compared to none
Odds of CVD Stratified by CRP Levels in U.S. Persons (Malik
and Wong et al., Diabetes Care 2005; 28: 690-3)
6
O
d
d
s
R
a
t
i
o
***
5
4
3
2
***
*
*
**
1
0
High CRP
No
Metabolic
disease
Syndrome
Low CRP
Diabetes
–*p<.05, **p<.01, **** p<.0001 compared to no disease, low CRP
–CRP categories: >3 mg/l (High) and <3 mg/L (Low)
–age, gender, and risk-factor adjusted logistic regression (n=6497)
Example of Significant Coronary Calcification
from Multidetector CT (Siemens Sensation 64)
scanner
10-Year CHD Event Rates (per 1000 person years) by
Calcium Score by CAC Categories in
Subjects with
Neither
Coronary
HeartMetS
Disease nor DM, MetS only, or DM
CHD events per 1000
person years
16.9
18
14.5
16
16.8
14
12.5
8.8
12
10
11.3
8
2
5.5
6
6.3
0.8
4
Diabetes DM
MetS
MetS
Neither MetS/DM
3.5
0.6
2
0
0
No MetS/DM
1-100
0
1-99
101-399
100-399
400+
400+
Coronary Artery Calcium Score
Malik and Wong et al. (AHA 2009)
Under-Treatment of Cardiovascular Risk
Factors Among U.S. Adults with Diabetes
– NHANES Survey 2001-2002, 532 (projected to 15.2 million)
or 7.3% of adults aged >/=18 years had diabetes
– 50.2% not at HbA1c goal <7%
– 64.6% not at LDL-C goal <100 mg/dl
– 52.3% not at recommended HDL-C >/=40 (M), >/=50 (F)
– 48.6% not at recommended triglycerides <150 mg/dl
– 53% not at BP goal of <130/80 mg/dl
– Overall, only 5% of men and 12% of women at goal
for HbA1c, BP, and LDL-C simultaneously
Malik S, Wong ND et al. Diab Res Clin Pract 2007;77:126-33.
Summary of Care:
ABC's for Providers
A
B
C
D
E
F
A1c Target
Aspirin Daily
Blood Pressure Control
Cholesterol Management
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
Exercise
Food Choices
Summary of Care:
ABC's for Providers
A A1c Target
Aspirin Daily
B
C
D
E
F
Blood Pressure Control
Cholesterol Management
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
Exercise
Food Choices
A1c Target
Aspirin Therapy
• A1c Target: In persons with diabetes,
glucose lowering to achieve normal to
near normal plasma glucose, as defined
by the HbA1c<7%
• Aspirin Daily: Patients with type 2 DM
>40 years of age or with prevalent CVD,
OR those with metabolic syndrome without
DM who are at intermediate or higher risk
(e.g., >=10% 10-year risk of CHD)
Type 2 Diabetes:
A1C Predicts CHD
CHD Mortality Incidence
(%) in 3.5 Years
*
12
All CHD Events Incidence
(%) in 3.5 Years
25
**
10
20
8
15
6
10
4
5
2
0
Low
<6%
Middle
6-7.9%
High
>7.9%
0
Low
<6%
A1C=hemoglobin A1C
*P<0.01 vs lowest tertile
**P<0.05 vs lowest tertile
Adapted with permission from Kuusisto J et al. Diabetes. 1994;43:960-967.
Middle
6-7.9%
High
>7.9%
UKPDS Relative Risk Reduction
for Intensive vs. Less Intensive Glucose Control
P=0.03
P=0.05
P=0.02
P<0.01
P<0.01
Over 10 years, HbA1c was 7.0% (6.2-8.2) in the intensive group (n=2,729)
compared with 7.9% (6.9-8.8) in the conventional group (n=1,138).
UKPDS Group. Lancet. 1998;352:837-853.
UKPDS Metformin Sub-Study:
CHD Events
Coronary Deaths
Myocardial Infarction
Incidence per 1000 patient years
20
10
p=0.01
p=0.02
NS
8
39%
Reduction
15
50%
Reduction
6
10
4
5
0
2
0
Conventional Insulin
SU’s
Diet
n=
#Events
411
73
UKPDS 34, Lancet 352: 854, 1998
951
139
Metformin
342
39
Conventional
Diet
Metformin
411
36
342
16
Recent Trials Show No Reduction in CV Events with
More Intensive Glycemic Control
25
20
Intensive therapy
Standard therapy
15
10
5
0
0
1
Number at Risk
Intensive 5128 4843
Standard 5123 4827
1ACCORD
ADVANCE: Primary Outcome
Cumulative incidence (%)
Patients with events (%)
ACCORD: Primary Outcome
2
3
Years
4390 2839
4262 2702
4
1337
1186
5
6
475
440
448
395
Study Group. N Engl J Med. 2008;358:2545-2559.
Collaborative Group. N Engl J Med. 2008;358:2560-2572.
2ADVANCE
25
20
Intensive therapy
Standard therapy
15
10
5
0
0
Number at Risk
Intensive 5570
Standard 5569
12
24
36
48
Months of follow-up
5369
5342
5100
5065
4867
4808
4599
4545
60
1883
1921
Was Intensive Glycemic Control Harmful?
A closer look at ACCORD AND ADVANCE
• ACCORD was discontinued early due to increased
total and CVD mortality in the intensive arm. Major
hypoglycemia 3-fold higher too.
• And the VA Diabetes Trial did show severe
hypoglycemia to be a powerful predictor of CVD
events.
• But a more recent analysis of ACCORD just
published (Diabetes Care, May 2010) showed
deaths to be associated with unsuccessful
intensive therapy where A1c remained high.
• However, in both ACCORD AND ADVANCE, the
subgroups without macrovascular disease at
baseline had an actual benefit in the primary
endpoint.
2009 ADA/AHA/ACC Statement
Recommendations
• Goal of A1c<7% remains reasonable
– for uncomplicated patients
• ACC/AHA Class I (A)
– and for those with macrovascular disease
• ADA Level B; ACC/AHA Class IIb (A)
• Incremental microvascular benefit may be
obtained from even lower goals
• ADA Level B; ACC/AHA Class IIa (C)
• Less stringent goals may be appropriate for
those with labile glucose control or with
advanced micro- or macrovascular disease
• ADA Level C; ACC/AHA Class IIa (C)
Circulation 2009; 119: 351-357
Summary of Care:
ABC's for Providers
A
A1c Target
Aspirin Daily
B Blood Pressure Control
C
D
E
F
Cholesterol Management
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
Exercise
Food Choices
Prevalence of Hypertension* in Adults
with Diabetes: NHANES III 1988-1994
% with Hypertension
100
80
72
75
66
60
Total
40
Men
Women
20
0
*BP ≥130/85 or therapy for hypertension
Geiss LS, et al. Am J Prev Med. 2002;22:42-48.
HTN Control Rate Remains Poor in US
Adults with MetS and DM from NHANES
2003-2004
(Wong ND et al., Arch Intern Med 2007)
• Only 35% of those with DM on treatment for
HTN are controlled to a goal of <130/80
mmHg
• Only 47% of those with MetS on treatment for
HTN have a blood pressure of <130/85 mmHg
• Thus, JNC-7 recommendations to begin with
combination therapy to improve goal
attainment should be adhered to, esp. if
SBP/DBP exceeds 20/10 mmHg from goal.
UKPDS: Effects of Tight vs. Less-Tight
Blood Pressure Control
UK Prospective Diabetes Study Group. BMJ. 1998; 317:703-713.
HOT Trial:
Effect of BP Control on CV Event Rate
Patients without Diabetes
Major
CV
events
per
1000
patient
-years
Patients with Diabetes
25
30
20
25
20
15
15
10
10
5
5
0
0
<90
<85
<80
<90
Diastolic Blood Pressure goal
Hansson L et al. Lancet. 1998;351:1755-1762.
<85
<80
ACCORD: Effects of Intensive BP
Control (NEJM 2010: 362: 1575-85)
• 4733 participants with type 2 DM randomly assigned
to intensive therapy targeting a SBP <120 mmHg vs.
standard therapy targeting a SBP<140 mmHg.
• Mean follow-up 4.7 years.
• SBP after 1 year was 119 vs. 133 mmHg.
• No difference in the primary endpoint of nonfatal MI,
stroke, or CVD death (annual rate): 1.9% vs. 2.1%
(HR=0.88), p=0.20.
• Stroke annual rates significantly lower 0.32% vs.
0.53%, HR=0.59, p=0.01. Thus, overall benefit may
be greater in populations with higher stroke risk.
Scientific Statements:
Diabetes, CV Disease and Hypertension
• JNC VII Report on Diabetic Hypertension
– BP goal (<130/80 mm Hg)
• Commonly requiring combinations of ≥2 drugs
– ACEIs, CCBs, Thiazide-diuretics, -blockers,
and ARBs shown to reduce CVD/CVA risk
– ACEIs/ARBs reduce progression of diabetic
nephropathy and reduce albuminuria
– ARBS reduce progression of macroalbuminuria
Grundy SM, et al. Circulation. 1999;100:1134-1146.
Chobanian AV, et al. JAMA. 2003;289:2560-2572.
Summary of Care:
ABC's for Providers
A
B
A1c Target
Aspirin Daily
Blood Pressure Control
C Cholesterol Management
D
E
F
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
Exercise
Food Choices
LDL-C as a Predictor of CAD
in Patients with Diabetes
2
1
0
70 mg/dl
98 mg/dl
118 mg/dl
151 mg/dl
LDL-C quartile mean
LDL=low-density lipoprotein cholesterol; CAD=coronary artery disease.
Adapted with permission from Howard BV et al. Arterioscler Thromb Vasc Biol. 2000;20:830-835.
Cumulative Hazard (%)
CARDS: Primary Endpoint
Relative Risk Reduction 37% (95% CI: 17-52)
15
P = 0.001
Placebo
127 events
10
Atorvastatin
83 events
5
0
0
Placebo 1410
Atorva 1428
1
1351
1392
Colhoun HM et al. Lancet 2004;364:685-96.
2
1306
1361
3
1022
1074
4
651
694
4.75
305
328
Years
HPS Substudy:
First Major Vascular Event by LDL-C and
Prior Diabetes Status
LDL-C and
diabetes status
Simvastatin
(10,269)
Placebo
(10,267)
With diabetes
191 (15.7%)
252 (20.9%)
No diabetes
407 (18.8%)
504 (22.9%)
410 (23.3%)
496 (27.9%)
1,025 (20.0%)
1,333 (26.2%)
2,033 (19.8%)
2,585 (25.2%)
Rate ratio (95% CI)
Statin better
Placebo better
<116 mg/dL
116 mg/dL
With diabetes
No diabetes
All patients
0.4
HPS Collaborative Group. Lancet. 2003;361:2005-2016.
24% reduction
(P<0.0001)
0.6
0.8
1.0
1.2
1.4
Reducing CVD Risk with Statin Therapy
in Patients with Diabetes
• Number needed to treat to prevent 1 major
CVD event
– From HPS and 4S
• Without coronary disease
• With coronary disease
14
4
– From meta-analysis
• Without vascular disease
39
• With vascular disease
19
HPS Collaborative Group. Lancet. 2003;361:2005-2016.
Pyorala K, et al. Diabetes Care. 1997;20:614-620
Kearney PM Lancet;2008:371:227-239
Lipid Goals for Persons with Metabolic
Syndrome and DM (Grundy et al., 2005)
LDL-C targets, ATP III guidelines
–High Risk: CHD, CHD risk equivalents (incl.
DM or >20% 10-year risk): <100 mg/dL
(option <70 mg/dl if CVD present)
– Moderately High Risk (10-20%) 2 RF: <130
mg/dL, option <100 mg/dL
– Moderate Risk (2+ RF, <10%) <130 mg/dL
-- Low Risk: 0-1 RF: <160 mg/dL
HDL-C: >40 mg/dL (men)
>50 mg/dL (women)
TG: <150 mg/dL
Specific Dyslipidemias:
Elevated Triglycerides
Non-HDL: Secondary Target
• Non-HDL = TC – HDL
• Non-HDL: secondary target of therapy
when serum triglycerides are 200
mg/dL (esp. 200-499 mg/dl)
• Non-HDL goal: LDL goal + 30 mg/dL
Specific Dyslipidemias:
Low HDL Cholesterol
Management of Low HDL
• LDL is primary target of therapy
• Weight reduction and increased physical
activity (if the metabolic syndrome is present)
• Non-HDL is secondary target of therapy (if
triglycerides 200 mg/dL)
• Consider nicotinic acid or fibrates (for patients
with CHD or CHD risk equivalents)
ACCORD Lipid Study Results
(NEJM 2010; 362: 1563-74)
• 5518 patients with type 2 DM treated with open
label simvastatin randomly assigned to
fenofibrate or placebo and followed for 4.7
years.
• Annual rate of primary outcome of nonfatal MI,
stroke or CVD death 2.2% in fenofibrate group
vs. 1.6% in placebo group (HR=0.91, p=0.33).
• Pre-specified subgroup analyses showed
possible benefit in men vs. women and those
with high triglycerides and low HDL-C.
• Results support statin therapy alone to reduce
CVD risk in high risk type 2 DM patients.
Summary of Care:
ABC's for Providers
A
B
C
D
E
F
A1c Target
Aspirin Daily
Blood Pressure Control
Cholesterol Management
Cigarette Smoking
Cessation
Diabetes and Pre-Diabetes
Management
Exercise
Food Choices
Smoking Cessation
• What you do does matter. Physicians who
intervene influence cigarette smoking behavior.
• How do you get your patients to quit smoking?
– Identify i.e.: in vitals signs
– Interventions as brief as 3 minutes can
significantly increase quit rates
– Dose dependent changes in behavior
– 5-10% may quit within 1 year with MD advice
alone
• Smoking cessation aids
EFFICACY OF SMOKING CESSATION
INTERVENTIONS (1 YEAR QUIT RATES)
ACUPUNCTURE
HYPNOSIS
-------
PHYSICIAN ADVICE
6%
SELF-HELP METHODS
14%
NICOTINE PATCH
11-15%
PHYSICIAN ADVICE/SELF-HELP PAMPHLETS
22%
AVERSIVE SMOKING (RAPID PUFFING)
25%
PHARMACOTHERAPY/BEHAVIORAL THERAPY 25%
BEHAVIORAL STRATEGIES (GROUP PROG.)
40%
The 5 “A’s” for Effective
Smoking Intervention
1. ASK about smoking
2. ADVISE to quit
3. ASSESS willingness to make a quit
attempt
4. ASSIST if ready - offer therapy and
consultation for quit plan and if not,
then offer help when ready
5. ARRANGE follow up visits
Summary of Care:
ABC's for Providers
A
B
C
A1c Target
Aspirin Daily
Blood Pressure Control
Cholesterol Management
Cigarette Smoking Cessation
D Diabetes and Pre-Diabetes
Management
E
F
Exercise
Food Choices
Incidence rate/1000
CHD Mortality Rates
(by Degree of Glucose Tolerance)
5
4
3
2
1
0
NGT
IGT
Diabetes*
*Indicates patients known to have diabetes prior to the study.
CHD=coronary heart disease; NGT=normal glucose tolerance; IGT=impaired glucose
tolerance
Adapted with permission from Eschwege E et al. Horm Metab Res Suppl. 1985;15:41-46.
Most Cardiovascular Patients Have
Abnormal Glucose Metabolism
GAMI
n = 164
31%
35%
34%
Normoglycemia
EHS
n = 1920
37%
18%
45%
Prediabetes
CHS
n = 2263
27%
37%
36%
Type 2 Diabetes
GAMI = Glucose Tolerance in Patients with Acute Myocardial Infarction study;
EHS = Euro Heart Survey; CHS = China Heart Survey
Anselmino M, et al. Rev Cardiovasc Med. 2008;9:29-38.
Diabetes Prevention Program:
Protocol Design
Diabetes Prevention Program:
Reduction in Diabetes Incidence
Benefit of Comprehensive, Intensive
Management: STENO 2 Study
Primary End Point=CV events (%)
60
• Treatment Goals:
–
–
–
–
–
Intensive TLC
HgbA1c <6.5%
Cholesterol <175
Triglycerides <150
BP <130/80
Conventional Therapy
Intensive Therapy
50
40
30
20
n =80
10
0
0
12
24
36
48
60
Months of Follow Up
Gaede, P. et al, NEJM 2003;348:390-393
n =80
72
84
96
Summary of Care:
ABC's for Providers
A
B
C
D
A1c Target
Aspirin Daily
Blood Pressure Control
Cholesterol Management
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
E Exercise
F
Food Choices
Metabolic Syndrome: Lifestyle
Management: Obesity / Physical Activity
• Obesity / weight management: low fat –
high fiber diet resulting in 500-1000 calorie
reduction per day to provide a 7-10%
reduction on body weight over 6-12 mos,
ideal goal BMI <25
• Physical activity: at least 30, pref. 60 min
moderate intensity on most or all days of
the week as appropriate to individual
Grundy SM, Hansen B, Smith SC, et al. Clinical management of metabolic syndrome. Report of the American
Heart Association / National Heart, Lung, and Blood Institute / American Diabetes Association
Conference on Scientific Issues Related to Management. Circulation 2004; 109: 551-556
Physical Inactivity: A Call to Arms
10,000 Steps Daily
30 minutes most days
Physical Activity
Recommendations
• Aerobic exercise a minimum of 30
minutes, 5 times weekly
• Optimal physical activity is at least 30
minutes daily
• Resistance exercise training using
free weights or machines 2 days a
week in the absence of
contraindications
Summary of Care:
ABC's for Providers
A
B
C
D
E
A1c Target
Aspirin Daily
Blood Pressure Control
Cholesterol Management
Cigarette Smoking Cessation
Diabetes and Pre-Diabetes
Management
Exercise
F Food Choices
ADA Nutritional Guidelines
• Patients with pre-diabetes should receive
individualized Medical Nutrition Therapy (MNT)
• Weight loss recommended for all overweight or
obese individuals who have or are at risk for
diabetes
• Physical activity and behavior modification
effective for weight loss and maintenance
• Fiber 14 g/1000 kcal intake
• Saturated fat 7% with minimal
trans fat
Therapeutic Lifestyle Changes
Nutrient Composition of TLC Diet
Nutrient
Recommended Intake
•
•
•
•
•
•
•
Less than 7% of total calories
Up to 10% of total calories
Up to 20% of total calories
25–35% of total calories
50–60% of total calories
20–30 grams per day
Approximately 15% of total
calories
Less than 200 mg/day
Balance energy intake and
expenditure to maintain
desirable body weight/
prevent weight gain
Saturated fat
Polyunsaturated fat
Monounsaturated fat
Total fat
Carbohydrate
Fiber
Protein
• Cholesterol
• Total calories (energy)
Effect of Mediterranean-Style Diet
in the Metabolic Syndrome
• 180 pts with metabolic
syndrome randomized to
Mediterranean-style vs.
prudent diet for 2 years
• Those in intervention
group lost more weight
(-4kg) than those in the
control group (+0.6kg)
(p<0.01), and significant
reductions in CRP and
Il-6
Esposito K et al. JAMA 2004; 292(12): 1440-6.
Conclusions
• Metabolic syndrome and diabetes are
associated with increased levels of
atherosclerosis and cardiovascular
disease event risk
• Lifestyle measures focusing on weight
reduction, dietary, and physical activity
guidance are crucial in initial
management.
Conclusions (cont.)
• Clinical management emphasizes
achievement of BP and lipid goals,
glycemic control, and antiplatelet therapy.
• Multidisciplinary programs including
primary care physicians, specialists
(endocrinologists and cardiologists),
dietitians, and exercise specialists are key
for the successful management of these
conditions.
Thank you for
your attention!
Now Published
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Healthcare …
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Question #1
Which of the following statements is
true?
a) Diabetes prevalence is higher in African
Americans and Hispanics compared to
Caucasians
b) The prevalence of diabetes is
approaching the prevalence of obesity
c) The impact of diabetes on CVD is
similar in men and women
d) All of the above
Question #2
What are the recommended target levels for
LDL-C and BP for most uncomplicated
patients with DM?
a)
b)
c)
d)
LDL-C <100 mg/dl and 120/80 mmHg
LDL-C <100 mg/dl and 130/80 mmHg
LDL-C <70 mg/dl and 140/90 mmHg
None of the above
Question #3
Diabetes has been considered a CHD risk
equivalent because:
a) Nearly all persons with CHD also have
diabetes
b) Persons with diabetes have a similar risk of
developing CHD than those who already
have CHD (e.g., myocardial infarction)
c) Both a and b
Question #4
Recent large clinical trials such as ACCORD
and ADVANCE suggest:
a) Aggressive glycemic control significantly
reduces the risk of future CVD events in high
risk persons with diabetes
b) The HbA1c target should be set closer to 6%
than the conventional target of <7%
c) A less stringent goal than <7% for HbA1c might
be considered in more complicated patients
with diabetes (e.g., those difficult to control, with
known macrovascular disease, or with longstanding diabetes)